Stage at breast cancer diagnosis and distance from diagnostic hospital in a periurban setting: A South African public hospital case series of over 1,000 women

Authors

  • Caroline Dickens,

    1. Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France
    2. Department of Internal Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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  • Maureen Joffe,

    1. Wits Health Consortium, MRC/Wits Developmental Pathways to Health Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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  • Judith Jacobson,

    1. Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, US
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  • Francois Venter,

    1. Information Management Directorate, Gauteng Provincial Department of Health, Bank of Lisbon, Johannesburg, South Africa
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  • Joachim Schüz,

    1. Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France
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  • Herbert Cubasch,

    1. Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
    2. Chris Hani Baragwanath Academic Hospital Breast Clinic, Soweto, South Africa
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  • Valerie McCormack

    Corresponding author
    1. Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France
    • Correspondence to: Valerie McCormack, Section of Environment and Radiation, International Agency for Research on Cancer, 150 cours Albert Thomas, Lyon 69008, France, Tel.: +33-4-72–73-85-66, Fax: +33-4-72–73-83-20, E-mail: mccormackv@iarc.fr

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  • Conflicts of interest: Nothing to report

Abstract

Advanced stage at diagnosis contributes to low breast cancer survival rates in sub-Saharan Africa. Living far from health services is known to delay presentation, but the effect of residential distance to hospital, the radius at which this effect sets in and the women most affected have not been quantified. In a periurban South African setting, we examined the effect of a geographic information system (GIS)-measured straight-line distance, from a patient's residence to diagnostic hospital, on stage at diagnosis in 1,071 public-sector breast cancer patients diagnosed during 2006–2012. Generalized linear models were used to estimate risk ratios for late stage (stage III/IV vs. stage I/II) associated with distance, adjusting for year of diagnosis, age, race and socioeconomic indicators. Mean age of patients was 55 years, 90% were black African and diagnoses were at stages I (5%), II (41%), III (46%) and IV (8%). Sixty-two percent of patients with distances >20 km (n = 338) had a late stage at diagnosis compared to 50% with distances <20 km (n = 713, p = 0.02). Risk of late stage at diagnosis was 1.25-fold higher (95% CI: 1.09, 1.42) per 30 km. Effects were pronounced in an underrepresented group of patients over age 70. This positive stage–distance association held to 40 km, and plateaued or slightly reversed in patients (9%) living beyond this distance. Studies of woman and the societal and healthcare-level influences on these delays and on the late stage at diagnosis distribution are needed to inform interventions to improve diagnostic stage and breast cancer survival in this and similar settings.

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